The consolidation of health care: 5 questions to ask

Comcast recently announced it is merging with Time Warner, the 2nd largest cable company in the US. Together, this deal nets Comcast an estimated 57% of the cable subscriber marketplace and heralds a new oligarchy in US media and entertainment. It’s big news for Comcast, but aren’t as excited.

Why?

Because both Comcast and Time Warner have been consistently rated the worst providers of customer service in the cable industry. Now as they grow their consumer base and build unprecedented influence in their field, the concerns are mounting. When choices are limited and quality is poor, what recourse do consumers have to demand more of their providers? And what will drive quality, cost containment, and new product development in a market vacuum where the experience of the consumer is at the periphery of the business? The risk is that, with little competition, consumers may be forced to choose between service and no service and the cost of services and breadth of services provided will be divorced from consumer demand.

No service isn’t such a problem when you are talking about cable. But did you know the same thing is happening with your health care?

Since 2009, there has been a surge in the number of hospital mergers and acquisitions. The name of the game is market share and across the country, hospitals, clinics, and in some cases even insurance plans and pharmacies, are combining forces to form large conglomerates that will control where, how, and at what price you receive your health care. This is being touted as the future of medicine, an organized system where regional populations receive coordinated care. The question is, will the consolidation of health care networks create a vacuum where patients’ choices are constrained within a narrowing marketplace? To answer that question, you need to know a bit of the back story.

Basically, the Affordable Care Act changes how we pay for (read: how profits are made off of) your health care and hospitals are realigning their relationships with each other and their referring clinics, to vie for your health care dollars. Now, instead of receiving care from independent physician practices and hospitals that contract with local doctors, most Americans will be placed into regional systems where the local physician practice not only works with the hospital, but is in many cases, owned by the hospital. Combined, the hospital and clinic will be given a lump sum of money to be accountable for your care (hence the name “accountable care organizations“). This new payment structure incentivizes collaboration between hospitals and clinics, distributes the costs of managing health and preventing disease across the system, and encourages the appropriate and thoughtful use of limited health care resources.

But despite these obvious advantages, there are some important things to consider as we enter this new oligarchical era in medicine:

1. While it may not be a problem if the hospital that owns your local clinic is down the street, what if it is in another town entirely, and like many working class families, you don’t have the resources to get there? Does regionalizing care create geographic barriers to access?

2. What if the hospital that buys your clinic charges higher prices? What recourse will patients have to ensure their care is affordable when clinics choose sides and the local options for providers dwindle? If this happens, will more patients opt for “no service” because they simply cannot afford the cost of care?

3. What will happen to the county hospital systems that rely on serving insured members of the community to offset the costs for serving those who do not have the ability to pay? Do large conglomerate hospital systems upset the local order by cherry picking insured patients out of the community and, in so doing, threaten the viability of public organizations that care for marginalized populations, including undocumented immigrants, children, and the poor?

4. How will quality be maintained across regions to ensure health equity? Will the quality of health care be higher in regions that serve higher income populations? And in areas with only 1 or 2 health care networks to choose from, particularly in rural America, how will patients’ needs impact quality measures and cost containment standards?

5. With such expansive reach into your health care experience, can a one-size-fits-all model really provide patient-centered care to populations with diverse sets of health care needs and priorities? Can health care conglomerates be too big to succeed?

In the end, the economic climate in medicine has changed and traditional independent physician practices are being forced to state their allegiances or risk extinction. It is the birth of big medicine and it is coming to an area near you. In a lot of ways, that’s good news. Integrated health systems promise to decrease the fragmentation in care delivery, provide continuity of services throughout regions, and build payment structures that may contain costs.

At the same time, building organizations that are too big to compete with and too expansive to be responsive to the ever-changing needs of the American consumer, risks alienating important populations from our health system, including children and the poor. The goal is to create organized models of care delivery, in which the sum of the whole is greater (read: more cost effective) than its individual parts.

As the business of medicine informs the practice of medicine in important and meaningful ways, the patient experience must remain at the center of the care we provide. Ultimately, it is patients and not profits that must be our impetus for change and our litmus for success.